Development of health IT an “unyielding principle” for China

Written by Kate McDonald on 11 August 2015.

China has seen huge growth in health information technology (HIT) adoption in the last five years, with 71 per cent of hospitals now having implemented an electronic medical record (EMR) – up from less than 30 per cent in 2009-10 – with a flow-on effect of greater adoption of other clinical information systems and applications.

However, while the growth has been large in pure numbers, the maturity of the EMRs in use is quite low and China faces the same obstacles to wider use of HIT as countries like Australia and the US do, according to Shen Tao, deputy director of the Chinese Hospital Information Management Association (CHIMA).

Mr Shen told the Health Informatics Conference (HIC 2015) in Brisbane last week that a lack of investment, lack of skilled IT staff and a plethora of vendors that are not delivering the advanced capabilities that governments, healthcare providers and consumers are now expecting and demanding are some of the major obstacles to further adoption of HIT.

And in this, Mr Shen said, China and the US are now experiencing similar problems. “As the biggest developing country, we are finally having the same characteristics with the biggest developed country,” he said.

Mr Shen was invited to provide an overview of CHIMA and the Chinese HIT sector to HIC following a visit by a delegation from CHIMA's counterpart, the Health Informatics Society of Australia (HISA), to CHIMA's annual conference in Xiamen, Fujian province, in June. HISA CEO Louise Schaper, chairman David Hansen and member Henry Zhuang all attended the conference, which hosted over 4000 delegates.

Mr Shen told HIC that CHIMA was first established in 1997, five years after HISA, and it is now the most important and influential HIT professional association in China.

Some of the details of the size of China's healthcare system are jaw-dropping: in a population of 1.368 billion people spread over 31 provinces, there are 974,400 medical institutions including 24,700 hospitals, and 9,790,000 clinicians, including 2,795,000 licensed doctors.

“In recent years we’ve been facing a lot of challenges and difficulties and our people are now paying more attention to their own health and quality of health services,” Mr Shen said.

“With development of our economy, chronic diseases have been a big burden for the economy, such as diabetes and high blood pressure. Our urbanisation has been accelerating [and] last year 50 per cent or more of our population has been [resident] in cities.

“Our ageing population is also a challenge that we are facing: it’s over 200 million aged people in our population (15 per cent). Even though we’ve been investing lots of money in our healthcare sector, we are still having problems satisfying the requirements of our people.”

While expenditure on healthcare is growing, it is still only 5.6 per cent of GDP, compared to 9.4 per cent for Australia and 17.1 per cent for the US. There is also an imbalance in investment in different regions in China with the eastern part of the country having a higher standard and more access to healthcare than the central and western regions.

HIT development in China since 2009-10

To help overcome growing levels of inequality, chronic illness and an ageing population, in March 2009 the Chinese government set its sights on reforming the healthcare system, and one area it has taken a close look at is the promotion of HIT.

According to Mr Shen, the focus has been on building capabilities such as EMRs, interoperability and telemedicine.

“From 2009 the government has launched many important reforms in our country,” he said, “and the core of this program is the hospital management and electronic medical record. It requires the hospitals in those cities and suburban areas to interact with each other, and to develop telemedicine to support remote areas.”

In November 2013, the government issued an overall framework for HIT throughout the country called '46312'. The number four refers to the four levels of healthcare management – national, provincial, municipal and cities – while the six refers to six different national health focus areas such as public health, family planning, medications management and insurance.

The three refers to three different national databases that have been established for demographic information, electronic health records and electronic medical records, the one refers to one national network for the health system, and the two means two different security systems.

The development of 46312 followed a national push for EMR adoption that began back in February 2010. That year, basic national specifications were developed, trialled and implemented, and the following year, the government developed a model of ranking EMRs called the MEG (model of EMR grading).

According to Mr Shen, this is used to assess the quality of EMR adoption, which is still quite low. CHIMA runs regular surveys of its member hospitals, and the most recent found that while there had been major growth in the implementation of EMRs, there was only one hospital that reached the highest level of grade 7. Only four hospitals reached grade 6, which includes closed-loop medications management and advanced clinical decision support.

However, what EMR adoption has done is drive the development and implementation of other clinical information systems, with most hospitals having implemented or are now implementing inpatient nurse and inpatient doctor workbenches, outpatient and emergency department doctor workbenches, laboratory and radiology information systems, clinical knowledge repository systems, ICU systems, pathology systems, PACS, and a variety of other information systems for clinical pathway management, infection control/hospital acquired infection surveillance, anaesthesia, telemedicine and regional health information.

“According to our survey, compared with five years ago, at the moment we have a very large adoption of EMR,” he said. “We can see that in different occasions the application and construction of clinical information system has been adopted quite well.”

The figures from CHIMA's 2014-15 survey show that 71 per cent of hospitals surveyed had implemented an EMR (up from 27.1 per cent in 2009-10), 7.7 per cent were planning to implement one and 21.2 per cent had no plans as yet. This was down from 38.3 per cent in 2009-10.

Mobile applications are also becoming very popular, with wireless networks, personal digital assistants, tablets, RFID, cloud and Internet of Things having a more active role compared to five years ago.

“Some examples here are the mobile nursing and mobile ward management [apps], as well as [apps for] equipment positioning and medical waste management,” he said. “We have lots of applications on our mobile phones, which allow our patients to make appointments, ask questions and do their payment.”

Self-service kiosks and single identity authentication are widely used, as is a social media application called WeChat that Mr Shen likened to Twitter.

The government has also launched a personal health information system for all patients called the Residents Healthcare Card that sounds similar to Australia's PCEHR. “By using this card we can include all information of the patient, including his or her medical history, and we are doing trials in 29 different provinces,” Mr Shen said.

Obstacles to HIT development in China

Mr Shen then outlined some of the challenges and obstacles facing the HIT industry in China, most of which will sound very familiar to other countries.

“According to our survey, the most serious obstacles that we are facing is first, money; second, staff; and third, vendors.”

CHIMA's survey of the status of China's hospital IT 2014-2015 showed that the challenges, in descending order, were: lack of adequate financial support, lack of staff, vendors' inability to deliver product, difficulty proving ROI, lack of medical data standards and a lack of a strategic IT plan.

“We have compared our results against the results from the US,” he said. “It’s almost the same. As the biggest developing country, we are finally having the same characteristics with the biggest developed country.

“The other obstacle that we are facing is talent. According to our survey ... on average there are nine full-time employees in IT departments in hospitals, whereas in America it’s 39 full-time employees.

“The other difficulty in talent is the training process. It is quite a long process, however the trainees cannot be well paid, and that is one of the reasons we are losing talent.”

In terms of vendors, the main problem is lack of expertise and low market concentration, he said. Of the 2622 hospitals that have undergone the MEG process, there are 320 different EMR vendors.

“The capability of our vendors is a big concern for us. They do not provide quality and enough facilities for us. One typical problem is that the vendors do not have a clear picture of how important medical information technology is to our hospital system.

“And for the vendors, they are also facing lack of talent on their side. We’ve noticed that with regards to EMR, the concentration in markets is still quite low.”

CHIMA's survey shows that users of the top 10 EMR products only account for about 30 per cent of the market, with users of the most popular product only 5.7 per cent of the market. China would like to see more concentration in this market, he said.

He also said there was an obstacle in the adoption of standards, particularly in the public healthcare sphere. While most hospitals are using ICD10 or ICD9, only 37 per cent are using HL7 and only six and five per cent respectively were using SNOMED and LOINC.

However, with large growth over the last few years and a government that is putting more focus on HIT, Mr Shen said he expects the market for HIT to keep improving.

“At the moment both the government and the people are requiring better services and they are paying more attention to their healthcare, so on the way to improving our quality and more services and to reduce the cost of our hospital system, we are still making efforts,” he said.

“In the words of Deng Xiaoping, 'development is an unyielding principle'. We are unyielding in this principle as well.”